Methods of assessing associated reactions of the upper limb in stroke and traumatic brain injury: A systematic review

Cardiorespiratory fitness assessment and training in the early sub-acute phase of recovery following traumatic brain injury: a systematic review

OBJECTIVES

To examine the safety of cardiorespiratory fitness (CRF) assessment and training in the early sub-acute phase of recovery (≤3 months) following moderate-to-extremely severe traumatic brain injury (TBI).

METHODS

A systematic review was completed in accordance with the PRISMA guidelines. Studies investigating adults and adolescents ≥15 years with moderate-to-extremely severe TBI were considered for inclusion. The methodological quality of the included studies was evaluated according to the McMaster Guidelines for Critical Review Form - Quantitative Studies.

RESULTS

Eleven studies with a total of 380 participants were included in the review. Adverse events (AEs) and symptom monitoring were poorly reported. Only four studies reported on the occurrence of AEs, with a total of eight AEs reported. Three of the reported AEs were concussion-like symptoms with no further exercise-induced symptom exacerbation reported. No serious AEs were reported.

CONCLUSION

There is no evidence to suggest that CRF assessment and training is unsafe in the early sub-acute phase of recovery following moderate-to-extremely severe TBI. However, despite the low AE and symptom exacerbation rates identified, a timeframe for safe commencement was unable to be established due to poor reporting and/or monitoring of exercise-induced symptoms and AEs in the current literature.

Treatment of spasticity

Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.

Flexor carpi radialis H-reflex in different body positions in patients with post-stroke

Background

Spinal stretch reflex (SSR) hyperexcitability reflected by the H-reflex has been reported in more strongly affected extremities after stroke. The H-reflex in the lower extremities is modulated by body position normally and alternatively modulated post-stroke.

Objective

This study aimed to preliminarily explore how upper extremity (UE) H-reflexes are modulated by body position after stroke, which remains unknown.

Materials and methods

Three patients after stroke with hemiparesis/hemiplegia were included. Bilateral flexor carpi radialis (FCR) H-reflexes were examined in the supine position while standing. Other clinical evaluations include the modified Ashworth scale (MAS) and postural stability measurement.

Results

The three cases herein showed that (1) SSR excitability was higher in more strongly affected UEs than less-affected UEs, (2) down-modulation of SSR excitability occurred in less-affected UEs in static standing compared with the supine position, but modulation of SSR excitability in more-affected UEs varied, and (3) bilateral UE SSR excitability in case 3 was down-modulated the most. Moreover, case 3 showed no difference in muscle tone of the more affected UE between supine and standing positions, and case 3 showed the best postural stability.

Conclusion

Spinal stretch reflex hyperexcitability in strongly affected UEs could commonly occur in different phases of recovery after stroke. Down-modulation of SSR excitability could occur in less-affected UEs in the standing position compared with the supine position, while modulation of SSR excitability might be altered in strongly affected UEs and vary in different phases of recovery. There could be some correlation between postural control and UE SSR hyperexcitability. The H-reflex may help to offer a new perspective on rehabilitation evaluation and interventions to promote UE motor control after stroke.

The timeframe for safe resumption of high-level mobility following traumatic brain injury is currently unknown: a systematic review

PURPOSE

To examine the safety of high-level mobility (HLM) prescription in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury (TBI) with specific focus on provocation of concussion-like symptoms.

DESIGN

Systematic review. PROSPERO ID: CRD42017069369.

MAIN MEASURES

Extracted data included study design, brain injury severity, time to commence HLM, type of HLM, physiological and symptom monitoring, and rate of adverse events.

RESULTS

Nineteen studies were included in the review. Fifteen studies included participants who commenced HLM within 6 weeks of injury, with the earliest time to commencement being 3 days. Overall, adverse events and symptom monitoring were poorly reported. A total of six adverse events were reported across three studies. One of the six adverse events was a concussion-like symptom. No falls were reported. No studies monitored concussion-like symptom provocation in direct relation to HLM.

CONCLUSION

A safe timeframe for return to HLM after moderate-to-extremely severe TBI could not be determined due to insufficient reporting of symptom monitoring and adverse events. Further research into the safety of HLM in the early sub-acute rehabilitative stage after moderate-to-extremely severe TBI is required in order to better understand potential sequelae in this population.IMPLICATIONS FOR REHABILITATIONHigh-level mobility assessment and training is commonly reported in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury.There is no consensus on a safe timeframe to commence high-level mobility assessment or training after moderate-to-extremely severe traumatic brain injury.High-level mobility assessment and training appears to be safe in the early sub-acute phase following moderate-to-extremely severe traumatic brain injury, however, adverse events and symptoms are poorly reported.Clinicians should continue to proceed with caution when assessing and prescribing high-level mobility for patients with moderate-to-extremely severe traumatic brain injury in the early sub-acute phase of recovery and monitor for risks such as falls and exacerbation of concussion-like symptoms.

Upper Limb Associated Reactions: The Relationship Between Movement Kinematics and Muscle Activity in Seated Versus Walking Testing

OBJECTIVE

The aims of this study were to (1) evaluate the relationships between stationary and dynamic associated reaction (AR) tests in people with acquired brain injury using surface electromyography (sEMG) muscle activity and three-dimensional motion analysis kinematic measures and (2) assess the test-retest reliability of sEMG and seated tests of ARs.

DESIGN

Forty-two adults with acquired brain injury underwent AR testing with seated contralateral maximal voluntary isometric contraction tests and walking (self-selected and fast speeds). Associated reaction measurements included biceps brachii sEMG, elbow goniometry, and three-dimensional motion analysis kinematics during walking. Pearson correlations evaluated the relationships between seated and dynamic walking AR tests and between muscle activity and kinematic measures. Chronic participants were reassessed 1 wk later for reliability.

RESULTS

A strong (r = 0.65) and moderate (r = 0.53) relationship existed for biceps brachii sEMG during seated and walking tests at self-selected and fast walk, respectively. A weak to moderate relationship existed between biceps brachii sEMG and kinematics during walking and between seated and walking measures of ARs (r = 0.23-0.53). All tests had strong to very strong test-retest reliability (intraclass correlation coefficients, >0.78).

CONCLUSION

Seated contralateral maximal voluntary isometric contraction tests correlate only weakly to moderately with AR walking kinematics and moderately to strongly with biceps brachii activation during walking. Moderate relationships exist between sEMG and kinematics, indicating that they may provide different information for ARs.

Effects of Self-Assisted Shoulder Elevation of the Affected Side Combined with Balance Training on Associated Reactions of Upper Limb and Walking Function in Chronic Stroke Patients: A Randomized Controlled Trial

Background

Associated reactions of the upper limb are frequently seen in stroke patients, especially during dynamic activities, such as walking. The aim of this study was to assess the effect of a method to inhibit the affected upper limb flexors combined with balance training on associated reactions of the affected upper limb and walking function in chronic stroke patients.

Material/Methods

60 patients were randomly allocated into 3 groups (n=20 per group): control group (no upper limb intervention), back group (the unaffected hand assists the affected upper limb in the low back and keep it in an extended position) and shoulder elevation group using the inhibition method (the unaffected hand assists the affected shoulder to elevate above 90°). Before and after the four-week balance training, the surface electromyography was used to evaluate the rate of contraction of affected elbow flexors. Fugl-Meyer Assessment of Upper Extremity (FMA-UE), 10 Meter Walking Test (10MWT) and Barthel Index (BI) were used to measure functional status.

Results

The shoulder elevation group had significant improvement in the percentage changes in the rate of contraction of the affected elbow flexors, 10WMT and FMA-UE (p<0.05) compared with back group and control group. We found no significant difference of 10WMT and FMA-UE between back group and control group.

Conclusions

The combination of the new inhibition method and the standing balance training could reduce the abnormal activity of affected elbow flexors during walking, increase walking speed, and improve the affected upper limb motor function.

Potential contributing factors to upper limb associated reactions in people with acquired brain injury: an exploratory study

PURPOSE

To determine which potential contributing factors are associated with upper limb associated reaction (AR) expression in individuals with acquired brain injury (ABI).

METHODS

Forty-two participants underwent three-dimensional motion analysis at self-selected walking speed to generate the AR outcome measure, quantifying their upper limb kinematic deviation compared to healthy controls. Clinical assessment included: upper and lower limb hypertonicity, spasticity and strength, balance, dynamic walking stability, arm and leg function, anxiety, arm pain/discomfort, and fear of falling.

RESULTS

Significant, moderate-to-strong correlations (r = 0.42-0.74, p < 0.05) existed between upper limb ARs and both hypertonicity and spasticity of the upper limb muscles and the knee extensors. Significant, moderate correlations to ARs (r = 0.42-0.59, p < 0.05) existed for balance, dynamic stability, upper limb strength, and arm function. The severity of AR was significantly different between those with and without hypertonicity of the four tested upper limb muscles, elbow and long finger flexor spasticity, knee extensor spasticity, and reduced dynamic stability (p < 0.05; effect sizes ≥0.80). However, these contributing factors were not present in all participants.

CONCLUSIONS

Associated reactions are complex and multi-factorial. There were several significant correlations indicating that factors may influence AR severity. While positive upper motor neuron syndrome features should be prioritised for clinical assessment, these factors are not prerequisites for ARs.IMPLICATIONS FOR REHABILITATIONUpper limb associated reactions are a complex and multi-factorial phenomenon.Upper limb muscle hypertonicity and spasticity should be prioritised for assessment; however, they are not prerequisites for associated reactions.Hypertonicity and spasticity should be differentiated as they may have differing relationships to associated reactions.Knee extensor hypertonicity and spasticity, postural stability, upper limb strength, and arm function may also be contributing factors to consider.

Restoration of arm and hand functions via noninvasive cervical cord neuromodulation after traumatic brain injury: a case study

Objectives: To investigate the effects of transcutaneous electrical stimulation (tES) on upper limb functional rehabilitation in a patient with traumatic brain injury (TBI), and to identify the optimum stimulation parameters of tES. Design: A preliminary case study. Methods: Two successive interventions: Phase I-voluntary physical training (vPT) and Phase II - tES along with vPT (tES+vPT). tES was delivered at C3 and C6 cervical regions. Clinical assessments presented the variation of muscle tone and motor functions, before and after each training phase, and evaluated at 1-month follow up after the last intervention. Results: Our results indicate that vPT alone contributed to a release of muscle spasticity of both arms of the patient with no significant improvement of hand function, while tES+vPT further reduced the spasticity of the left arm, and improved the voluntary motor function of both arms. The grip forces were also increased after the tES+vPT treatment. We found that 1 ms biphasic tES at 30 Hz produced optimum motor outputs. Conclusion: The study demonstrates, for the first time, the potential benefits of cervical tES in regard to improving upper limb motor functions in a patient with chronic TBI.

Quantification of abnormal upper limb movement during walking in people with acquired brain injury

BACKGROUND

Abnormal upper limb movements frequently affect people with acquired brain injury (ABI) during walking. Three-dimensional motion analysis (3DMA) can quantify upper limb abnormality kinematically, with composite scores condensing multiple joint axes data into a single score.

RESEARCH QUESTION

Are 3DMA-derived composite scores valid (known-groups and convergent validity), reliable and able to quantify speed-related changes in abnormal upper limb movement during walking?

METHODS

This observational study compared 42 adults with ABI and abnormal upper limb movements during walking with 36 healthy controls (HC) at a matched walking speed intention. Participants underwent 3DMA assessment of self-selected and fast walking speeds. Composite scores quantified the affected upper limb's kinematic abnormality. The Arm Posture Score arithmetic mean version (APSam) and 1.96 standard deviation reference-range scaled versions; the Kinematic Deviation Score mean (KDSm) and worst score (KDSw) were evaluated for association with each other and subjective abnormality rating (Pearson's 'r' correlation), test-retest reliability (intra-class correlation coefficient (ICC)), and ability to quantify speed-related changes in abnormal upper limb movement (Cohen's d effect size (ES), % change scores).

RESULTS

Very strong correlations existed between composite scores. The KDSm under-classified upper limb abnormality, whereas the KDSw captured the majority of ABI participants. All scores had moderate-strong correlations with subjective rating of abnormal upper limb movements (r = 0.54 - 0.79) and very strong test-retest reliability (ICCs > 0.81). The APSam demonstrated a 16% (ES = 0.76) walking speed-related increase in upper limb abnormality, whilst decreases were demonstrated in the KDSm 26% (ES 0.90) and KDSw 35% (ES 0.96).

SIGNIFICANCE

The APSam, KDSw, and number of abnormal joint axes comprehensively assess the whole upper limb abnormal movements, accurately classifies abnormality, and quantifies severity. This study illustrated notable presence of abnormal upper limb movements at self-selected walking speed and small increase at fast speeds. However, when scaled to HC variability, the fast walk kinematics became less abnormal due to increased HC movement variability.

Flexors activity of affected upper extremity in stroke patients during different standing conditions and their relationships with clinical scales: a cross-sectional study

Purpose: To explore the flexors activity of affected upper extremity in stroke patients during different standing conditions and their relationships with clinical scales.Materials and methods: Sixteen stroke patientswere recruited, all subjects stood on balance equipment with four different standing postures. The electromyogram (EMG) simultaneously recorded the muscle activity of bilateral biceps brachii, triceps brachii, flexor carpi radialis and extensor carpi radialis and their integrated electromyogram were figured out the contraction rate of elbow flexors(biceps brachii/triceps brachii) and wrist flexors(flexor carpi radialis/extensor carpi radialis). All subjects were assessed using Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), Berg Balance Scale (BBS), Barthel Index (BI) and Modified Ashworth Scale (MAS).Results: The contraction rate of affected elbow flexors in the condition of feet together on soft surface was significantly higher than that in the condition of feet separatedon hard surface (P < 0.05). The contraction rate of affected elbow flexors in four standing conditions tended to increase, all the values of which were greater than numerical value1. The difference in the contraction rate of elbow flexor between the affected side and the unaffected side was statistically significant (P < 0.05). No correlation was observed between the contraction rate of the elbow flexor and the results of MAS, FMA-UE, BBS and BI regardless of the standing conditions.Conclusions: The contraction rates of elbowflexor in the affected side increase with the difficulty in different standing postures,and it may be a good index to reflect the changes of muscle tone in postural control.

The nature and extent of upper limb associated reactions during walking in people with acquired brain injury

BACKGROUND

Upper limb associated reactions (ARs) are common in people with acquired brain injury (ABI). Despite this, there is no gold-standard outcome measure and no kinematic description of this movement disorder. The aim of this study was to determine the upper limb kinematic variables most frequently affected by ARs in people with ABI compared with a healthy cohort at matched walking speed intention.

METHODS

A convenience sample of 36 healthy control adults (HCs) and 42 people with ABI who had upper limb ARs during walking were recruited and underwent assessment of their self-selected walking speed using the criterion-reference three dimensional motion analysis (3DMA) at Epworth Hospital, Melbourne. Shoulder flexion, abduction and rotation, elbow flexion, forearm rotation and wrist flexion were assessed. The mean angle, standard deviation (SD), peak joint angles and total joint angle range of motion (ROM) were calculated for each axis across the gait cycle. On a group level, ANCOVA was used to assess the between-group differences for each upper limb kinematic outcome variable. To quantify abnormality prevalence on an individual participant level, the percentage of ABI participants that were outside of the 95% confidence interval of the HC sample for each variable were calculated.

RESULTS

There were significant between-group differences for all elbow and shoulder abduction outcome variables (p < 0.01), most shoulder flexion variables (except for shoulder extension peak), forearm rotation SD and ROM and for wrist flexion ROM. Elbow flexion and shoulder abduction were the axes most frequently affected by ARs. Despite the elbow being the most prevalently affected (38/42, 90%), a large proportion of participants had abnormality, defined as ±1.96 SD of the HC mean, present at the shoulder (32/42, 76%), forearm (20/42, 48%) and wrist joints (10/42, 24%).

CONCLUSION

This study provides valuable information on ARs, and highlights the need for clinical assessment of ARs to include all of the major joints of the upper limb. This may inform the development of a criterion-reference outcome measure or classification system specific to ARs.

The reproducibility and responsiveness of subjective assessment of upper limb associated reactions in people with acquired brain injury during walking

Objective:

The aim of this study is to determine inter-rater, test–retest and intra-rater reproducibility and responsiveness of subjective assessment of upper limb associated reactions in people with acquired brain injury using (1) the ‘Qualifiers Scale’ of the International Classification of Functioning, Disability and Health Framework, and (2) visually estimated elbow flexion angle during walking.

Design:

Observational study.

Setting:

A brain injury rehabilitation centre, Melbourne, Australia.

Subjects:

People with acquired brain injury and upper limb associated reactions and experienced neurological physiotherapists.

Main measures:

The Qualifiers Scale applied to individual upper limb joints and global associated reaction on a 5-point scale (0–4), a summed upper limb severity score and visually estimated elbow flexion angle.

Results:

A total of 42 people with acquired brain injury (mean age: 48.4 ± 16.5 years) were videoed walking at self-selected and fast speeds. A subset of 30 chronic brain injury participants (mean time post injury: 8.2 ± 9.3 years) were reassessed one week later for retest reproducibility. Three experienced neurological physiotherapists (mean experience: 22.7 ± 9.1 years) viewed these videos and subjectively rated the upper limb associated reactions. Strong-to-very strong test–retest, intra- and inter-rater reproducibility was found for elbow flexion angle (ICC > 0.86) and the Qualifiers Scale applied to global and individual upper limb joints (ICC > 0.60). Responsiveness of change from self-selected to fast walking speed (mean increase 0.46 m/s) was highest for elbow flexion angle (effect size = 0.83) and low-to-moderate for the Qualifiers Scale.

Conclusion:

Subjectively rated associated reactions during walking demonstrated strong reproducibility and moderate responsiveness to speed change. The Qualifiers Scale and elbow flexion angle can both subjectively quantify associated reactions during walking in a clinical setting.

Motor Overflow and Spasticity in Chronic Stroke Share a Common Pathophysiological Process: Analysis of Within-Limb and Between-Limb EMG-EMG Coherence

The phenomenon of exaggerated motor overflow is well documented in stroke survivors with spasticity. However, the mechanism underlying the abnormal motor overflow remains unclear. In this study, we aimed to investigate the possible mechanisms behind abnormal motor overflow and its possible relations with post-stroke spasticity. 11 stroke patients (63.6 ± 6.4 yrs; 4 women) and 11 healthy subjects (31.18 ± 6.18 yrs; 2 women) were recruited. All of them were asked to perform unilateral isometric elbow flexion at submaximal levels (10, 30, and 60% of maximum voluntary contraction). Electromyogram (EMG) was measured from the contracting biceps (iBiceps) muscle and resting contralateral biceps (cBiceps), ipsilateral flexor digitorum superficialis (iFDS), and contralateral FDS (cFDS) muscles. Motor overflow was quantified as the normalized EMG of the resting muscles. The severity of motor impairment was quantified through reflex torque (spasticity) and weakness. EMG-EMG coherence was calculated between the contracting muscle and each of the resting muscles. During elbow flexion on the impaired side, stroke subjects exhibited significant higher motor overflow to the iFDS muscle compared with healthy subjects (ipsilateral or intralimb motor overflow). Stroke subjects exhibited significantly higher motor overflow to the contralateral spastic muscles (cBiceps and cFDS) during elbow flexion on the non-impaired side (contralateral or interlimb motor overflow), compared with healthy subjects. Moreover, there was significantly high EMG-EMG coherence in the alpha band (6–12 Hz) between the contracting muscle and all other resting muscles during elbow flexion on the non-impaired side. Our results of diffuse ipsilateral and contralateral motor overflow with EMG-EMG coherence in the alpha band suggest subcortical origins of motor overflow. Furthermore, correlation between contralateral motor overflow to contralateral spastic elbow and finger flexors and their spasticity was consistently at moderate to high levels. A high correlation suggests that diffuse motor overflow to the impaired side and spasticity likely share a common pathophysiological process. Possible mechanisms are discussed.